Universal Intake Form Page 2
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4Universal Intake Form
Page 2
Income & Asset Sources
Monthly Income: Borrower
Monthly Income: Co-Borrower
Wages (before taxes)
$ __________________
Wages (before taxes)
$ __________________
Unemployment Income
$ __________________
Unemployment Income
$ __________________
Child Support/Alimony*
$ __________________
Child Support/Alimony*
$ __________________
SSI/SSDI
$ __________________
SSI/SSDI
$ __________________
Retirement/Pension
$ __________________
Retirement/Pension
$ __________________
Rents received
$ __________________
Rents received
$ __________________
Other
$ __________________
Other
$ __________________
Gross Monthly Income: $ __________________
Gross Monthly Income: $ __________________
Net Monthly Income** $ __________________
Net Monthly Income**: $ __________________
*Alimony, child support, or separate maintenance income need not be revealed if Borrower or Co-Borrower does not want it considered for repaying this loan.
**Gross income, less Federal/State/Local taxes, FICA, 401K deductions, etc.
Besides income sources, please circle additional resources available to pay towards defaulted mortgage:
401(k), 403(b), CDs, IRAs, Money Market, Family/Friends, Other
Amount available: $
Expenses
Monthly
Annual
Total Owed
Total Mortgage Payment
(including Principal & Interest.,
Property Taxes, H/O Insurances, H/O Ass’n Dues)
$ _____________
$ _____________
If not escrowed, Property Taxes
$ _____________
$ _____________
If not escrowed, H/O Insurance
$ _____________
$ _____________
If not escrowed, Homeowner Associations Dues
$ _____________
$ _____________
Auto Expenses (gas, maintenance, etc.)
$ _____________
$ _____________
Auto Insurance
$ _____________
$ _____________
Credit Cards
$ _____________
$ _____________
Child Care, Alimony, Child Support:
$ _____________
$ _____________
Food (Groceries, Eating Out, Snacks):
$ _____________
$ _____________
Utilities (gas, electric, water, sewer, and garbage)
$ _____________
$ _____________
Communications (cell phone, telephone, internet)
$ _____________
$ _____________
Miscellaneous Spending Money:
$ _____________
$ _____________
Auto Loans: Year ______ Make & Model ____________ $ _____________
$ _____________
$ _____________
Auto Loans: Year ______ Make & Model ____________ $ _____________
$ _____________
$ _____________
Installment Loans:
$ _____________
$ _____________
$ _____________
Medical Expenses:
$ _____________
$ _____________
$ _____________
Student Loans:
$ _____________
$ _____________
$ _____________
Home Equity Loans, outstanding balances
$ _____________
$ _____________
$ _____________
TOTAL MONTHLY EXPENSES:
$ _____________
MONTHLY SURPLUS/SHORTFALL (Total Monthly Income minus Total Monthly Expenses):
$ ______________
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Parent category: Business